VATS Left S8 Lung Segmentectomy With Radiological Coil and ICG

The author reports the case of a vats left S8 segmentectomy. In this case, they used a coil to precisely localize the small lesion. The surgery began with pleural inspection, and then they started, as for any pulmonary oncological resection, by a radical mediastinal lymph node dissection. They moved next to the fissure, where they identified the pulmonary artery and controlled it with a vessel loop. Then they went to the hilum, and a station 10 lymph node dissection was performed.

The author used blunt dissection to control the anterior part of the fissure and opened it with a stapler. The next step consists of identifying the arterial branches for S8. They followed the artery and performed a station 12 lymph node dissection. This lymph node was sent in frozen section and went back as normal. In the case of suspicious cells being found, the author would have performed a lobectomy.

At the time of this video, the author didn’t have 3D reconstruction in routine. Since they had doubt in front of these two arterial branches, they decided to check vascularization with the help of indocyanine green before cutting the controlled artery. Thanks to a fluorescent camera, they could visualize the vascularized parenchyma. They saw the lesion crossing the demarcation line highlighting the need to expand the resection and to cut the artery at the first level controlled with the vessel loop.

The segmental resection seemed to be oncologically satisfactory with sufficient margins. After the artery, they took the bronchus. They also sent to frozen section the station 12 lymph node to eliminate a more advanced disease than supposed. Care was taken not to injure the artery and V6 during dissection. After controlling the bronchus for S8, they clamped it and checked with an inflation test, which allowed them to verify S9-10 and S6 good ventilation. Just under the bronchus, they dissected the superior basilar vein. Before stapling the parenchyma, bronchovascular stumps were released to ensure removal in the operative specimen. The intersegmental lines were marked with electrocoagulation to separate S8 from S9-10 and S8 from S6.

The specimens were removed with the lesion in the middle of the resection, warranting security margins. The author controlled stumps of the artery, the bronchus, and the vein, then looked into the good expansion of the remaining segments.

This video advocates for sparing the lung in case of small lesion with the help of ICG and frozen section.

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